Role of Echocardiography in the Assessment of Myocardial Viability Symbol

doi:10.1097/MAJ.0b013e3181a39391

The American Journal of the Medical Sciences

Volume 337, Issue 5, May 2009, Pages 349-354

https://doi.org/10.1097/MAJ.0b013e3181a39391 Get rights and content

Abstract

In the assessment of chronic myocardial infarction, echocardiography plays a vital role through the recognition of hibernating yet potentially viable myocardium that could benefit from revascularization. Echocardiography provides information through basic evaluation of cardiac structure and through evaluation of the functional response to dobutamine stress. In addition, a number of newer modalities such as myocardial contrast echocardiography, tissue Doppler imaging, and strain imaging provide further diagnostic capability. This review assesses the role of echocardiography in the identification of patients with chronic myocardial infarction who could benefit from revascularization.

Section snippets

Stunned and Hibernating Myocardium

To address this jeopardized but viable myocardium, the concepts of stunned myocardium and hibernating myocardium were introduced. Stunned myocardium refers to the prolonged but reversible contractile dysfunction that can occur in patients with transiently impaired coronary perfusion that undergo restoration of normal resting blood flow with no permanent tissue damage.8., 9. Stunning can occur in the aftermath of an acute myocardial infarction (MI) in which there is prompt revascularization,

Echocardiography for Viability Detection: LV Morphology

In the assessment of chronic MI, echocardiography plays a vital role through the recognition of hibernating yet potentially viable myocardium that could benefit from revascularization. The simplest form of assessment for functional recovery potential by echocardiography addresses LV morphology. Patients with severely dilated LVs, despite evidence of viability by other modalities, are unlikely to show functional improvement with revascularization.²⁶ The higher the LV end-systolic volume, the

Echocardiography for Viability Detection: DSE

DSE has long been used to assess jeopardized myocardium for viability. Viability is shown by noting improved contraction of a dysfunctional LV wall segment with low-dose dobutamine infusion, which provides adrenergic stimulation. In patients with jeopardized but viable myocardium, the LV ejection fraction will show improvement with low-dose dobutamine in direct proportion to the number of segments with contractile reserve.³⁵ Potential disadvantages of DSE include poor acoustic windows in some

Echocardiography for Viability Determination: Myocardial Contrast Echocardiography

Although DSE has excellent specificity for the identification of hibernating myocardium, its sensitivity tends to be lower than the other imaging modalities. The addition of myocardial contrast echocardiography (MCE) to DSE has been investigated in the effort to improve the diagnostic accuracy of echocardiography for prediction of viability in patients with chronic ischemic heart disease. Myocardial perfusion is necessary for cellular viability, and myocardial necrosis is associated with loss

Echocardiography for Viability Determination: Tissue Doppler Imaging

Tissue Doppler imaging (TDI) has been studied for the assessment of regional ventricular function, because it measures point velocities of the myocardium.⁶¹ The use of TDI for viability prediction, however, has been limited by its lack of site specificity. The segment of interest can be “tethered” by neighboring segments so that its velocity is influenced by the neighboring segments. TDI parameters including peak systolic velocity, isovolumetric contraction, and time-to-peak systolic velocity

Echocardiography for Viability Determination: Strain and Strain Rate Analysis

Strain and strain rate are derived from TDI data but overcome the main limitation of TDI, because they allow differentiation between passive tethering and active thickening, isolating the region of interest. However, strain and strain rate are Doppler techniques, so they are limited by angle dependence. Strain is defined as the change in length between myocardial contraction and relaxation expressed as a percentage, while strain rate measures the velocity gradient between 2 points in space,

CONCLUSION

In the evaluation of chronic MI, echocardiography is useful for the identification of hibernating myocardium that could show functional improvement with revascularization. The use of DSE with qualitative wall motion analysis alone is highly specific yet less sensitive than other diagnostic tests for the identification of hibernating myocardium. However, the addition of newer echocardiographic modalities such as MCE, TDI, and strain has the potential to improve the diagnostic performance of DSE

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Postoperative monitoring is essential for detecting early complications and improving the salvage rate of free flaps. We propose a new protocol for free flap monitoring based on the combination of near-infrared spectroscopy (NIRS) and ultrasound.
All free flaps with a skin paddle were included and divided into two groups according to the immediate postoperative monitoring method used: ultrasound examination (control group) or those monitored using our protocol (study group). The number of surgical revisions, intraoperative findings, immediate flap failure, sensitivity, and specificity were compared between the two groups.
A total of 221 free flaps performed in 209 patients were included. The NIRS automatically detected vascular compromise in 21.8% of cases. A complication was confirmed in half of these cases by ultrasound examination, and surgical reintervention was indicated (10.9%), even in the absence of clinical changes in the skin paddle. In all the surgical revisions, the complication was confirmed, and there was no flap necrosis in the non-revised cases. The salvage rate for revised flaps and the flap survival rate were higher in the study group (salvage rate: 25% vs 72.7%; survival rate: 92.5% vs 97%). A sensitivity of 100% and a specificity of 100% were found for the combination of both monitoring methods.
The proposed protocol is a non-invasive and reliable method for early identification of postoperative complications of free flaps that allows higher rates of salvage rate and reduces the need for specific staff with continuous on-site presence for flap monitoring.
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Cardiovascular magnetic resonance (CMR) provides a variety of methods of obtaining information on residual viability after myocardial infarction. Indirect signs of viability that can be observed by CMR are any sign of wall thickening at rest (which is detectable with high accuracy by cine CMR), wall thickening after stimulation by low-dose dobutamine, preserved wall thickness, and a preserved viable epicardial rim. On the other hand, myocardial necrosis is characterized by late gadolinium enhancement (LGE) (possibly with a low-intensity core region due to no reflow) of the infarct area after injection of gadolinium, reduced wall thickness (in chronic infarcts) without a substantial viable rim, and the absence of a contractile reserve during dobutamine stimulation. Evaluation of viable myocardium is most important in patients with severe left ventricular (LV) dysfunction because these patients can gain most from revascularization if substantial amounts of myocardium are present. Recent data from the Surgical Treatment for Ischemic Heart Failure (STICH) trial questioned the value of viability imaging for improving outcome in these patients. Unfortunately, the information available about the value of CMR techniques in identifying patients with global LV dysfunction who have a high likelihood of profiting from a coronary revascularization is still scarce. Low-dose dobutamine CMR may be less accurate than LGE CMR in this patient group. In patients with regional LV dysfunction, however, in whom the need for revascularization needs to be established, both dobutamine CMR and LGE CMR are well validated and can be used clinically. Depiction of zones of acute necrosis by observing enhancement after gadolinium carries substantial promise for detailed studies of the effects of different treatment strategies for acute myocardial infarction as well as for treatment in the early and late postinfarction phase. In contrast, CMR may not be able to hold its initial promise for identifying the area at risk and distinguish it from the area of infarction.
Global longitudinal speckle-tracking strain is predictive of left ventricular remodeling after coronary angioplasty in patients with recent non-st elevation myocardial infarction
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To test whether two-dimensional longitudinal strain (2DSE) performed after revascularization by percutaneous coronary intervention (PCI) could predict left ventricular (LV) remodeling in patients with recent non-ST elevation myocardial infarction (NSTEMI).
In 70 patients (62.7 ± 8.7 years) with recent NSTEMI (between 72 hours and 14 days), undergoing coronary angiography for recurrent angina, myocardial deformation parameters were measured by 2DSE before and 24 hours after reperfusion therapy. Strain in all LV segments was averaged to obtain a global value (Global longitudinal Strain – GLS). Infarct size was estimated by clinical parameters and cardiac markers. After 6 months from intervention, LV negative remodeling was defined as lack of improvement of LV function, with increase in LV end-diastolic volume of greater than or equal than 15%.
At follow-up, patients were subdivided into remodeled (n = 32) and non-remodeled (n = 38) groups. Patients with negative LV remodeling had significantly lower baseline LV ejection fraction (44.8 ± 6.9 vs. 48.7 ± 5.5 %; p < 0.05), higher peak troponin I (p < 0.001) and reduced GLS (- 10.6 ± 6.1 vs - 17.6 ± 6.7 % p < 0.001) than those without LV remodeling. GLS showed a close correlation with peak troponin I after PCI (r = 0.64, P < 0.0001) and LV WMSI (r = 0.42, p < 0.01). By multivariable analysis, diabetes mellitus (P < 0.005), peak of Troponin I after PCI (P < 0.0005), GLS at baseline (OR: 4.3; p < 0.0001), and lack of improvement of GLS soon after PCI (OR: 1.45, P < 0.01) were powerful independent predictors of negative LV remodelling at follow-up. In particular, a GLS ≤ 12 % showed a sensitivity and a specificity respectively of 84.8% and 87.8% to predict negative LV remodelling at follow-up.
in patients with recent NSTEMI, longitudinal LV global and regional speckle-tracking strain measurements are powerful independent predictors of LV remodeling after reperfusion therapy.
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The aim of this study was to develop a simple and reasonably precise echocardiographic method for the assessment of infarct size (IS) and cardiac dysfunction in mice after myocardial infarction.
In vivo experiments were performed in C57BL/6J wild-type mice (n = 18) before and 48 hours after left anterior descending coronary artery ligation. Endocardial length-based echocardiographic IS was validated with that by three different histologic measurements. Left ventricular function was evaluated.
Excellent agreement was found between endocardial length-based echocardiographic measurement and angle-based histologic measurement of IS (r = 0.82, P < .001), and both methods strongly correlated with Tei index (r = 0.82, P < .001, and r = 0.74, P < .01) and fractional area change (r = −0.61, P < .05, and r = −0.81, P < .001).
Endocardial length-based echocardiographic measurement proved to be a useful method for assessing myocardial IS and is applicable for biomedical and imaging research, and appears particularly promising in studies of left ventricular remodeling after myocardial infarction.
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The evaluation of coronary microvascular obstruction in patients with STEMI by cardiac magnetic resonance T2-STIR image and layer-specific analysis of 2-dimensional speckle tracking echocardiography combined with low-dose dobutamine stress echocardiography
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Cardiology Grand Rounds From Emory UniversityRole of Echocardiography in the Assessment of Myocardial Viability Symbol

Abstract

Section snippets

Stunned and Hibernating Myocardium

Echocardiography for Viability Detection: LV Morphology

Echocardiography for Viability Detection: DSE

Echocardiography for Viability Determination: Myocardial Contrast Echocardiography

Echocardiography for Viability Determination: Tissue Doppler Imaging

Echocardiography for Viability Determination: Strain and Strain Rate Analysis

CONCLUSION

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am Heart J

Chest

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Curr Probl Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Am Coll Cardiol

Heart Lung Circ

Am J Cardiol

Int J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

Chronic heart failure in the United States: a manifestation of coronary artery disease

Circulation

Long-term trends in the incidence of and survival with heart failure

N Engl J Med

Influence of direct myocardial revascularization on left ventricular asynergy and function in patients with coronary heart disease: with and without previous myocardial infarction

Circulation

Cardiology Grand Rounds From Emory University
Role of Echocardiography in the Assessment of Myocardial Viability Symbol